Mental health policy and practice across Europe: an overview

Financing and funding 91
community cohesion. However, this should not be interpreted as meaning that
cost savings must be found before there can be investment in mental health.
Many cost-effective interventions are also cost increasing, so reformers should
not need to be defensive about requiring increased levels of expenditure for
better outcomes (Knapp 2005).
As we saw in the section on resource targeting, some areas of mental health
practice are relatively well provided with evidence; for example, many of the
most frequently used treatments for schizophrenia and depression have been
the subject of cost-effectiveness evaluations. On the other hand, there have
been relatively few economic evaluations of mental health promotion strategies.
Given the general finding that economic evidence, unlike most of the
evidence coming from clinical studies, does not generalize well from one health
system or country to another, there needs to be encouragement for research
endeavours that can generate solid platforms of local cost-effectiveness and
related evidence on the range of therapeutic and service options available
within a mental health care system. Given the cost and time needed to generate
new evidence, serious consideration needs to be given to how these results
might be adapted from another setting or country. This is one of a number of
tasks now being explored by the European Commission-supported Mental
Health Economics European Network.
The WHO’s ongoing CHOICE (Choosing Interventions that are Cost Effective)
programme has put together a database on cost-effectiveness evidence for many
mental health interventions in Europe. This information, while not at a countryspecific
level, is provided for three European sub-regions in a transparent
manner so that data can potentially be adapted to take account of local priorities,
costs and resource availability (Chisholm et al. 2004, 2005). This database
confirms that cost-effective treatments are available for all of Europe, even
where resources for health are very limited.
Assuming that policy-makers can be convinced of the merits of greater
investment in mental health, how might this be achieved? Options include
expansion of the overall health budget, prioritization of mental health and/or
the protection of mental health funds via ring-fenced budgets. There are, of
course, disadvantages as well as advantages in the latter, for ring-fenced budgets
can stop resources flowing in as well as out, and can encourage isolationism and
reinforce negative images of the ‘special’ nature of mental illness. Another
option in some countries, where there is sufficient data on resource utilization
and costs, may be to introduce diagnosis-related group (DRG) unit costs. In
principle, well constructed DRGs can be an effective way of ensuring that sufficient
resources are transferred to secondary and specialist mental health
related services. There is, of course, a danger, as highlighted by recent experiences
in Austria (see Box 4.1), that the complexity of mental health might mean
that DRG costs are underestimated (Zechmeister et al. 2002). This is a general
problem with chronic conditions.
Resource inequity is another major challenge. Information gathering and
lobbying on local prevalence data, cost-of-illness studies, disability burden
figures, quality of life descriptions, cost-effectiveness evidence and antidiscrimination
efforts could all assist. Fairer allocation of resources is likely to be
achieved through the reduction of income-related inequity, finding ways of